Prostate assessment

Prostate gland

The prostate is a walnut-sized gland that forms part of the male reproductive system. One of its main roles, is the secretion of fluid into the urethra as sperm move through during ejaculation. This fluid helps make up semen, energises the sperm by producing nutrients for the sperm.

Prostate problems

• Problems related to the prostate are very common and become more common with increasing age.
• Benign Prostatic Hyperplasia (BPH) – Caused by enlargement of the central part (transition zone) of the prostate.
• Prostate cancer – typically affects the outer ‘rim’ (peripheral zone) of the prostate.
• Prostatitis – an inflammatory condition of the prostate, which is not always caused by infection.

Benign prostatic hyperplasia

It is common for the prostate gland to become enlarged as a man ages. Doctors call this condition benign prostatic hyperplasia (BPH), or benign prostatic hypertrophy or benign prostatic enlargement.

As a man matures, the prostate goes through two main periods of growth. The first occurs early in puberty, when the prostate doubles in size. At around age 25, the gland begins to grow again. This second growth phase often results, years later, in BPH.

Though the prostate continues to grow during most of a man’s life, the enlargement doesn’t usually cause problems until late in life. BPH rarely causes symptoms before age 40, but more than half of men in their sixties and as many as 90 percent in their seventies and eighties have some BPH related symptoms.

As the prostate enlarges, the layer of tissue surrounding it stops it from expanding, causing the gland to press against the urethra like a clamp on a garden hose. The bladder wall becomes thicker and irritable. The bladder begins to contract even when it contains small amounts of urine, causing more frequent urination. Eventually, the bladder weakens and loses the ability to empty itself, so some of the urine remains in the bladder. The narrowing of the urethra and partial emptying of the bladder cause many of the problems associated with BPH.

Many people feel uncomfortable talking about the prostate, since the gland plays a role in both sex and urination. Still, prostate enlargement is as common a part of aging as gray hair. As life expectancy rises, so does the occurrence of BPH.

Why BHP occurs

The cause of BPH is not well understood. No definite information on risk factors exists. For centuries, it has been known that BPH occurs mainly in older men and that it doesn’t develop in men whose testes were removed before puberty. For this reason, some researchers believe that factors related to aging and the testes may spur the development of BPH.

Throughout their lives, men produce both testosterone, an important male hormone and small amounts of oestrogen, a female hormone. As men age, the amount of active testosterone in the blood decreases, leaving a higher proportion of oestrogen. Studies done on animals have suggested that BPH may occur because the higher amount of oestrogen within the gland increases the activity of substances that promote cell growth.

Another theory focuses on dihydrotestosterone (DHT), a substance derived from testosterone in the prostate, which may help control its growth. Most animals lose their ability to produce DHT as they age. However, some research has indicated that even with a drop in the blood’s testosterone level, older men continue to produce and accumulate high levels of DHT in the prostate. This accumulation of DHT may encourage the growth of cells. Scientists have also noted that men who do not produce DHT do not develop BPH.

Some researchers suggest that BPH may develop as a result of “instructions” given to cells early in life. According to this theory, BPH occurs because cells in one section of the gland follow these instructions and “reawaken” later in life. These “reawakened” cells then deliver signals to other cells in the gland, instructing them to grow or making them more sensitive to hormones that influence growth.

Symptoms

Many symptoms of BPH stem from obstruction of the urethra and gradual loss of bladder function, which results in incomplete emptying of the bladder. The symptoms of BPH vary, but the most common ones involve changes or problems with urination, such as:

‘Obstructive’ bladder symptoms include having to wait to get started, a poor urinary flow and needing to strain to pass urine. In some patients, the back-pressure caused by the obstruction separates nerve endings from the bladder muscle fibres they are travelling towards, causing the bladder to behave in a reflex manner rather like a baby’s bladder does.

The ‘irritative’ symptoms caused by an unstable bladder include frequency (going often), urgency (going in a hurry) and urge incontinence (leaking if you can’t get to a toilet in time).

Other BPH symptoms relate to the stagnation of urine, which can lead to urinary infection (pain on and frequency of passing urine) or stone formation (recurrent urinary infections and frequency) and rarely, the symptoms of kidney failure.

The size of the prostate does not always determine how severe the obstruction or the symptoms will be. Some men with greatly enlarged glands have little obstruction and few symptoms while others, whose glands are less enlarged, have more blockage and greater problems.

Sometimes a man may not know he has any obstruction until he suddenly finds himself unable to urinate at all. This condition, called acute urinary retention, may be triggered by taking over-the-counter cold or allergy medicines. Such medicines contain a decongestant drug, known as a sympathomimetic. A potential side effect of this drug may prevent the bladder opening from relaxing and allowing urine to empty. When partial obstruction is present, urinary retention also can be brought on by alcohol, cold temperatures, or a long period of immobility.

It is important to tell your doctor about urinary problems such as those described above. In eight out of 10 cases, these symptoms suggest BPH, but they also can signal other, more serious conditions that require prompt treatment. These conditions, including prostate cancer, can be ruled out only by a doctor’s examination.

Severe BPH can cause serious problems over time. Urine retention and strain on the bladder can lead to urinary tract infections, bladder or kidney damage, bladder stones and incontinence—the inability to control urination. If the bladder is permanently damaged, treatment for BPH may be ineffective. When BPH is found in its earlier stages, there is a lower risk of developing such complications.

Diagnosis

You may first notice symptoms of BPH yourself, or your doctor may find that your prostate is enlarged during a routine check up. When BPH is suspected, you may be referred to a urologist, a doctor who specializes in problems of the urinary tract and the male reproductive system. Several tests help the doctor identify the problem and decide whether surgery is needed. The tests vary from patient to patient, but the following are the most common

• Digital Rectal Examination (DRE) – This examination is usually the first test done. The doctor inserts a gloved finger into the rectum and feels the part of the prostate next to the rectum. This examination gives the doctor a general idea of the size and condition of the gland.
• Prostate-Specific Antigen (PSA) blood test – Prostate Specific Antigen (PSA) is a protein produced by prostate cells which is often higher in the blood of men who have prostate cancer and is detected by performing a blood test. However, an elevated level of PSA does not necessarily mean you have cancer. PSA test is used in conjunction with Digital Rectal Examination (DRE) of the prostate to help detect prostate cancer in men and for monitoring men with prostate cancer after treatment. However, much remains unknown about how to interpret the PSA test, its ability to discriminate between cancer and benign prostate conditions and the best course of action if the PSA is high.
• Dynamic urine flow study and bladder ultrasound – Your doctor may ask you to urinate into a special device that measures how quickly the urine is flowing. A reduced flow often suggests BPH. It is always advisable to try to attend your urologist clinic with a relatively full bladder as this test is often required. An ultrasound scan of your bladder will follow the urine flow test to see if your bladder is still retaining significant volumes of urine.
• Urodynamics – Urodynamics testing may be indicated if you have a problem with frequent voiding, an urgent or difficult-to-control desire to void, urine leakage or reduced urine flow. This is the “gold standard” assessment of lower urinary tract symptoms and helps your specialist see measure how much urine your bladder can hold, how the pressure changes inside your bladder with increasing volume and how these factors relate to your urge to urinate. Whilst you lie on a couch, a small catheter (tube) is gently passed through the penis and into the bladder; another is passed into the rectum to record pressure there as well. As the test progresses, your bladder are slowly filled with sterile water and you will be asked about bladder sensation and any desire to pass water. Once your bladder is full, you will be asked to pass urine; the catheters remain in place to measure the pressure in your bladder as you pass urine. This pressure-flow study can identify bladder outflow obstruction and show whether you have prostate enlargement or stricture (tightening) in the urethra. We can tell you the results of the tests immediately afterwards and decide on a treatment plan.
• Cystoscopy – Cystoscopy or telescopic inspection of the bladder is usually performed in patients with ‘irritative’ bladder symptoms to exclude physical bladder irritants, such as a stone or bladder cancer, which are unusual. It can be performed awake using a local anaesthetic gel and using a flexible telescope. This procedure is well tolerated by most patients, however, on some occasions a general anaesthetic may be required. Post procedure, there might be transient blood in the urine and a stinging sensation as the local anaesthetic jelly wears off.

Treatment

• Alternative treatments for BPH:
  Nutrition and the use of supplements and herbs can be used to modify the metabolism of testosterone and oestrogen and so reduce prostate size and hopefully symptoms.
• Nutrition – Eat less dairy products, refined food, fried foods, hydrogenated oils, alcohol and caffeine.
• Eat more fruit, vegetables, whole grains, soy, beans, seeds, nuts, olive oil and cold-water fish (salmon, tuna, sardines, halibut and mackerel).
• Supplements – Zinc – 30–50 mg daily. Zinc competes with copper for absorption; therefore, when supplementing long term with zinc, copper should also be supplemented. There are supplements available that contain both zinc and copper.
• Herbs – Saw palmetto – reduces the size of the prostate via its oestrogenic effect and so relieves symptoms of BPH. Recommended dosage is 320 mg of extract a day.

Medical treatments for BPH:
Over the years, researchers have tried to find a way to shrink or at least stop the growth of the prostate without using surgery. There are currently two classes of medical therapy available to relieve common symptoms associated with an enlarged prostate.

Finasteride (Proscar) and dutasteride (Avodart), inhibit production of the hormone DHT, which is involved with prostate enlargement. The use of either of these drugs can either prevent progression of growth of the prostate or actually shrink the prostate in some men.

The other class of drugs are called alpha blockers. These include Tamsulosin (Flomax) and Alfuzosin (Xatral). These drugs act by relaxing the smooth muscle of the prostate and bladder neck to improve urine flow and to reduce bladder outlet obstruction.

The Medical Therapy of Prostatic Symptoms (MTOPS) Trial, supported by the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), recently found that using Finasteride and Doxazosin together is more effective than using either drug alone to relieve symptoms and prevent BPH progression. The two-drug regimen reduced the risk of BPH progression by 67 percent, compared with 39 percent for Doxazosin alone and 34 percent for Finasteride alone.

Surgical treatment:
Most doctors recommend removal of the enlarged part of the prostate as the best long-term solution for patients with BPH. With surgery for BPH, only the enlarged tissue that is pressing against the urethra is removed; the rest of the inside tissue and the outside capsule are left intact. Surgery usually relieves the obstruction and incomplete emptying caused by BPH. The following section describes the types of surgery that are used.

Transurethral resection of the prostate (TURP) involves coring out the central part of the prostate (rather like one might core out the centre of an apple) to physically enlarge the channel one passes urine through. It was the first ‘keyhole’ operation and remains the standard to which other operations for BPH are compared. It is performed under general or spinal anaesthetic, usually lasts 45 minutes and involves no incisions on the outside. It is performed using an electrical loop inserted into the urethra via a telescope. It cuts tissue and seals blood vessels  as it removes the prostate in slivers. These are washed out at the end of the operation and a catheter is inserted for 2 days, through which irrigation fluid flows into the bladder to rinse any blood in it.

Patients are discharged from hospital 48hours following TURP and should avoid heavy physical exercise for 2 weeks. Urinary flow is usually markedly improved immediately but frequency may take 6-12 weeks to completely settle. All patients experience retrograde ejaculation after TURP i.e. sperm going back into the bladder at the time of climax, rather than coming out of the penis and being washed out of the bladder the next time it is emptied. There is also a 5% risk of impotence after TURP, usually in men aged over 70 years.

Open surgery – In the few cases when a transurethral procedure cannot be used, open surgery, which requires an external incision, may be used. Open surgery is often done when the gland is greatly enlarged, when there are complicating factors, or when the bladder has been damaged and needs to be repaired. General anaesthesia is given and an incision is made. Once the surgeon reaches the prostate capsule, he or she scoops out the enlarged tissue from inside the gland.

Newer procedures that use laser technology can be performed on an outpatient basis.

GreenLight^TM photoselective vaporisation of the prostate (PVP) – PVP uses a high-energy laser to vaporize prostate tissue and seal the treated area. Its advantages over TURP are less bleeding and a much shorter catheterisation time and hospital stay. The procedure is performed via a telescope inserted into the urethra under spinal or general anaesthetic and usually lasts 30-60 minutes.

Holmium Enucleation of Enlarged Prostate (HoLEP) – Uses Holmium laser technology to enucleate the enlarged adenomatous prostate. The procedure is also performed via a telescope inserted into the urethra under spinal or general anaesthetic and usually lasts 30-60 minutes.

Your recovery after surgery in the hospital

The amount of time you will stay in the hospital depends on the type of surgery you had and how quickly you recover.

At the end of surgery, a special catheter is inserted through the opening of the penis to drain urine from the bladder into a collection bag. Called a Foley catheter, this device has a water-filled balloon on the end that is put in the bladder, which keeps it in place.

This catheter is usually left in place for a couple of days. Sometimes, the catheter causes recurring painful bladder spasms the day after surgery. These spasms may be difficult to control, but they will eventually disappear.

You may also be given antibiotics while you are in the hospital. Many doctors start giving this medicine before or soon after surgery to prevent infection.  This is often the case if you already have a urethral catheter as this increases he risk of infection.

After surgery, you will probably notice some blood or clots in your urine as the wound starts to heal. If your bladder is being irrigated (flushed with water), you may notice that your urine becomes red once the irrigation is stopped. Some bleeding is normal and it should clear up by the time you leave the hospital. During your recovery, it is important to drink a lot of water (up to 8 cups a day) to help flush out the bladder and speed healing.

Do’s and don’ts

Take it easy the first few weeks after you get home. You may not have any pain, but you still have an incision that is healing—even with transurethral surgery, where the incision can’t be seen. Since many people try to do too much at the beginning and then have a setback, it is a good idea to talk with your doctor before resuming your normal routine. During this initial period of recovery at home, avoid any straining or sudden movements that could tear the incision. Here are some guidelines:

• Continue drinking a lot of water to flush the bladder.
• Avoid straining when having a bowel movement.
• Eat a balanced diet to prevent constipation. If constipation occurs, ask your doctor if you can take a laxative.
• Don’t do any heavy lifting.
• Don’t drive or operate machinery.

Getting back to normal after surgery

Even though you should feel much better by the time you leave the hospital, it will probably take a couple of months for you to heal completely. During the recovery period, the following are some common problems that can occur.

Problems urinating

You may notice that your urinary stream is stronger right after surgery, but it may take a while before you can urinate completely normally again. After the catheter is removed, urine will pass over the surgical wound on the prostate and you may initially have some discomfort or feel a sense of urgency when you urinate. This problem will gradually lessen and after a couple of months you should be able to urinate less frequently and more easily.

• Incontinence
  As the bladder returns to normal, you may have some temporary problems controlling urination, but long-term incontinence rarely occurs. Doctors find that the longer problems existed before surgery, the longer it takes for the bladder to regain its full function after the operation.
• Bleeding
  In the first few weeks after transurethral surgery, the scab inside the bladder may loosen and blood may suddenly appear in the urine. Although this can be alarming, the bleeding usually stops with a short period of resting in bed and drinking fluids. However, if your urine is so red that it is difficult to see through or if it contains clots or if you feel any discomfort, be sure to contact your doctor.

Sexual function after surgery

Many men worry about whether surgery for BPH will affect their ability to enjoy sex. Some sources state that sexual function is rarely affected, while others claim that it can cause problems in up to 30 percent of cases. However, most doctors say that even though it takes awhile for sexual function to return fully, with time, most men are able to enjoy sex again.

Complete recovery of sexual function may take up to 1 year, lagging behind a person’s general recovery. The exact length of time depends on how long after symptoms appeared that BPH surgery was done and on the type of surgery. Following is a summary of how surgery is likely to affect the following aspects of sexual function.

Erections

Most doctors agree that if you were able to maintain an erection shortly before surgery, you will probably be able to have erections afterward. Surgery rarely causes a loss of erectile function. However, surgery cannot usually restore function that was lost before the operation.

Although most men are able to continue having erections after surgery, a prostate procedure frequently makes them sterile (unable to father children) by causing a condition called retrograde ejaculation or dry climax.

During sexual activity, sperm from the testes enters the urethra near the opening of the bladder. Normally, a muscle blocks off the entrance to the bladder and the semen is expelled through the penis. However, the coring action of prostate surgery cuts this muscle as it widens the neck of the bladder. Following surgery, the semen takes the path of least resistance and enters the wider opening to the bladder rather than being expelled through the penis. Later it is harmlessly flushed out with urine. In some cases, this condition can be treated with a drug called pseudoephedrine, found in many cold medicines, or imipramine. These drugs improve muscle tone at the bladder neck and keep semen from entering the bladder.

Orgasm

Most men find little or no difference in the sensation of orgasm, or sexual climax, before and after surgery. Although it may take some time to get used to retrograde ejaculation, you should eventually find sex as pleasurable after surgery as before.

Many people have found that concerns about sexual function can interfere with sex as much as the operation itself. Understanding the surgical procedure and talking over any worries with the doctor before surgery often help men regain sexual function earlier. Many men also find it helpful to talk with a counsellor during the adjustment period after surgery.

Is further treatment needed?

In the years after your surgery, it is important to continue having a rectal examination once a year and to have any symptoms checked by your doctor.

Since surgery for BPH leaves behind a small part of the gland, it is still possible for prostate problems, including BPH, to develop again. However, surgery usually offers relief from BPH for at least 15 years. Only 10 percent of the men who have surgery for BPH eventually need a second operation for enlargement. Usually these are men who had the first surgery at an early age.

Sometimes, scar tissue resulting from surgery requires treatment in the year after surgery. Rarely, the opening of the bladder becomes scarred and shrinks, causing obstruction. This problem may require a surgical procedure similar to transurethral incision (see section on Surgical Treatment). More often, scar tissue may form in the urethra and cause narrowing. The doctor can solve this problem during an office visit by stretching the urethra.

BPH and prostate cancer: no apparent relation

Although some of the signs of BPH and prostate cancer are the same, having BPH does not seem to increase the chances of getting prostate cancer. Nevertheless, a man who has BPH may have undetected prostate cancer at the same time or may develop prostate cancer in the future. For this reason, the National Cancer Institute and the American Cancer Society recommend that all men over 40 have a rectal examination once a year to screen for prostate cancer.

After BPH surgery, the tissue removed is routinely checked for hidden cancer cells. In about one out of 10 cases, some cancer tissue is found, but often it is limited to a few cells of a nonaggressive type of cancer and no treatment is needed.